Psychological Distress Through Immigration: the Two-Phase Temporal Pattern?

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International Journal of Social Psychiatry

Psychological Distress Through Immigration: the Two-Phase Temporal Pattern? Michael Ritsner and Alexander Ponizovsky International Journal of Social Psychiatry 1999; 45; 125 DOI: 10.1177/002076409904500205 The online version of this article can be found at:

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large community sample, cross-sectional and in part longitudinal design, and comparison groups was used to determine the timing of psychological distress among immigrants. A total of 2,378 adult immigrants from the former Soviet Union to Israel completed the self-administered questionnaire Talbieh Brief Distress Inventory. The aggregate levels of distress and six psychological symptoms obsessiveness, hostility, interpersonal sensitivity, depression, anxiety, and paranoid ideation - were compared at 20 intervals covering 1 to 60 months after resettlement. The level of psychological distress was significantly higher in the immigrants than that of Israeli natives but not in the potential immigrant controls. A two-phase temporal pattern of development of psychological distress was revealed consisting of escalation and reduction phases. The escalation phase was characterized by an increase in distress levels until the 27th month after arrival (a peak) and the reduction phase led to a decline returning to normal levels. The 1-month prevalence rate was 15.6% for the total sample, and for highly distressed subjects it reached 24% at the 27th month after arrival, and it declined to 4% at the 44th month. The time pattern of distress shared males and females, married and divorced/widowed (but not singles), as well as subjects of all age groups (except for immigrants in their forties). The two-phase pattern of distress obtained according to cross-sectional data was indirectly confirmed through a longitudinal way. Claims of early euphoric or distress-free period followed by mental health crisis frequently referred to in the literature on migration was not supported by this study. INTRODUCTION is conceptualized as a process of change in different perspectives: the intrapsychic, the social-psychological and that of inter-cultural relations (Kuo, 1976; Hertz, 1988, 1993; Berry, 1990). It is often a difficult process learning to cope with numerous hardships and anxieties created by settling in to a new environment (Grinberg & Grinberg, 1984), which contributes to development of psychological distress (demoralization, acculturative stress) among new immigrants (Westermeyer et al. 1984; Flaherty et al. 1986; Kohn et al. 1989; Ritsner et al. 1996; Factourovich et al. 1996; Ponizovsky et al. 1997). Most researchers view immigration as a U-shaped process: the immigrant’s initial elation on arriving in the host society is soon replaced by feelings of distress and dissatisfaction at difficulties encountered, feelings which gradually fade as he/she adapts to


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Saunders (1976) identified 4 phases of (Leherer, 1993). Brink & immigrant adaptation: the &dquo;honeymoon phase&dquo;, &dquo;disenchantment phase&dquo;, &dquo;beginning resolution phase&dquo;, and &dquo;effective function phase&dquo;. Rumbaut (1985) suggested a model with two stages: a euphoric period, and a mental health crisis. According to Sluzki’ss model (1986) all migrants pass through two stages of adaptation in a new country: overcompensation followed by a major crisis in mental health. Berry & Kim (1988) considered the degree of cultural and psychological change and attendant stress phenomena as a function of 5 phases (precontact, contact, conflict, crisis, and adaptation). According to this model psychological distress will linearly increase in transition from the precontact to the crisis phase, and then it will vary depending on an outcome of adaptation processes (assimilation, integration, separation, and marginalization). Hertz (1988, 1993) suggested 3 major stages (pre-immigration, coping and settlement stages), with additional sub-phases within the coping stage (the impact level or the initial period with positive feeling, the rebound level or distress period, and the coping level or adjustment period). Although many studies have demonstrated higher distress among recent immigrants, many questions remain rather unclear. Thus, most researchers support an initial euphoric phase and suggest that the distress may last three months to seven years following immigration (Nguyen, 1984; Boman & Edwards, 1984; Sokoloff et al., 1984; Rumbaut, 1985; Barwick, 1986; Sluzki, 1986; Flaherty et al., 1986, 1988). For example, Tyhurst (1982) suggested that the




increase of mental health risk


between 6 and 12 months after resettlement.

According to Sluzki (1986) the overcompensation lasts for six months, and a stage of major crisis 6 months to 6 years. Pernice and Brook (1996) did not support of Sluzki’s model. These researchers found that of 249 refugees and immigrants, neither those under six months residence in New Zealand were symptom free nor those with six months to six years of residence demonstrated a deterioration in mental health. This cross-sectional study has certain methodological limitations: a mixed ethnicity sample, the mix of refugees together with voluntary immigrants and a small number of subjects for most time periods. Those few studies that have used representative, community-based samples or longitudinal design, demonstrated controversial results. Westermeyer et al. (1984, 1989) studying psychosocial adjustment of 100 Hmong refugees, showed considerable improvement on psychiatric self-rating scales during their first decade in the United States. Those premigration and postmigration variables that were correlated with high level of symptoms at 1.5 years, did not show significant correlation at 3.5 years after resettlement. Changes demonstrated considerable evidence of acculturation, psychiatric care seeking and greatly reduced symptom levels for several symptom complexes. Depression, somatization, phobia and selfesteem were most improved over time, while anxiety, hostility and paranoid symptoms remained unchanged. ~eiser’s findings (1988) from a representative community sample of refugees with use of both cross-sectional and longitudinal data, were consistent with Westermeyer et ccl.’s (1984, 1989) data: refugees experienced better mental health the longer they stayed in the new country. In contrast, Scott and Scott (1989) using a sample of mixed ethnicity and a longitudinal design did not find major differences in distress levels during the first years after immigrating to Australia. When one considers changes in psychological distress levels over time on an individual level, different tendencies in the course of distress are recognized (Ritsner et al. 1997). In that study, a 1-year follow-up of 199 recent immigrants from the ex-Soviet Union to Israel showed

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major patterns of change in distress. The &dquo;normal&dquo; pattern, with a permanent low level of distress, was observed among 44% respondents, the &dquo;positive&dquo; pattern, with either persistent moderate or decreasing levels of distress (33%) and the &dquo;negative&dquo; pattern, with either persistent high or increasing levels of distress (23%). Thus, the data show that the individual trends in the course of distress should be taken into account for an analysis of phase-related mental health risks in immigrants. In summary, all investigators recognize the importance of systematic consideration of the adjustment process among immigrants, but due to some methodological limitations, their results are controversial and inconclusive. What course will the psychological distress of immigrants take? Does an early euphoric (symptom-free) period exist preceding a period of major crisis in their mental health? How long can distress period last? Despite the large body of literature, the answers to these questions remain unclear. The 1990s became witness to the largest wave of Jewish immigration from the former 3

Soviet Union to different countries in the Western world. The main reason for this exodus was the drastic political change occurring in the country in the late 1980s. Israel admitted more than 700,000 immigrants between 1989 and 1997. The peak of the exodus fell in 19911 and 1992, when more than 200,000 people per year came to the country. The Russian immigrants, mainly urban people with high educational levels and reasonable familiarity with western culture, preferred to settle largely in cities all over Israel, increasing the population of these locations approximately by 10%. In the present study, we examined cross-sectional and partly longitudinal data on a nationwide, representative population of adult Russian-born Jewish immigrants to determine the time frame on psychological distress over the first 5 years of their residence in Israel. In addition, we sought to determine the time variation of psychological distress with sex, age, and marital status affecting adaptation to a new environment.

METHOD Data collection This study was part of the Immigrant Psychological Distress Project (IPDP) undertaken since 1991. Sociodemographic, background and clinical findings on the diverse sections of the IPDP have been reported in detail elsewhere; in particular, levels and symptoms of distress, sources of adjustment difficulties and social support were assessed in different immigrant subpopulations, such as physicians, psychiatric outpatients, consumers of supporting housing (Ritsner et al. 1993; 1996; Factourovich et al. 1996; Ponizovsky et al. 1996; Ponizovsky &

Perl, 1997). IPDP-database contains a community survey data on 2,713 subjects, aged 111 and over, who immigrated from the ex-Soviet Union to Israel between 1989 and 1996. years All subjects were recruited from 7 cities: Jerusalem, Tel Aviv, Ashkelon, Rehovot, RishonLe-Zion, Haifa and Beersheba. The data have been collected through two community sampling methods: a survey of typical immigrant services, and a household survey. By using the first method, 1,306 respondents were approached at language instruction and professional retraining courses, at hostels and social services (a convenience sample). Data was collected at these institutions from immigrants present at the administration data,


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including 75%-90% of the available list of all immigrants registered at each of the above settings. Overall, very few immigrants (N 15, 1.3%) refused to participate in this study. A comparison of participants with refusals showed no significant differences in any of the demographic variables, which were surveyed (sex, age, years of education, family composition and time elapsed since immigration). To eliminate possible bias related to using populations from the specific settings, this convenience sample was supplemented by a household sample of 1,407 respondents who =

the inclusion criteria. Data was collected from respondents who resided in several neighborhoods of the same cities in accordance with available lists of immigrants’ addresses by a &dquo;door-to-door&dquo; procedure. The respondents completed the questionnaires privately, in their homes, at a time convenient to them, in their native language. The no-response rate comprised 10% (due to changes in address of subjects polled prior to the administration date). met

Subjects A cross-sectional analysis of the association between levels of psychological distress and time since immigration was performed with a large sample of immigrants extracted from the IPDP-database according to the two inclusion criteria: age at examination of 20 to 69 years, and duration of stay in Israel under 5 years. A total of 1,250 subjects of the convenience sample and 1,068 subjects of the household sample met these criteria. Comparisons between the two subsamples were made for demographics and clinical variables to determine if sampling procedure had an effect on the study results. Because the subsamples were quite comparable by their sociodemographic and clinical characteristics, they were grouped together. Thus, the total sample of 2,318 subjects was formed and used for analyses below. In the total sample, 957 were males (41.3%) and 1,361 were females (58.7%). The male/ female ratio as well as the age distributions of subjects in the study sample was close to that found in the total Russian immigrant population in Israel (N 299,839; 45.2% males and 54.8% females; the mean age 40.7 years, SD in terms of sex-age structure, Thus, 12.3). the sample can be considered representative of the total population of Russian immigrants. The average time in Israel was 23.7 months (SD = 15.1): 29.4% had immigrated within 1 year of the study, 28.9% within 1 to 2 years, 23.3% within 2 to 3 years, 8.9% within 3 to 4 years, and 8.2% within 4 to 5 years. A longitudinal analysis was carried out on a subsample of 199 subjects (extracted from the total sample) which has been examined twice for a 1-year time-interval. Sampling, and details about the subsample have been described more fully elsewhere (Ritsner et al. 1997). Briefly, by door-to-door case-finding the initial list of recent immigrants living in two Jerusalem neighboring residential areas was checked, and 457 adult subjects were located. Initial interviews were conducted with 419 of them (8.3% refused to participate) and follow-up interviews were performed with 199 subjects (49% of the initial sample) 12 months later. By sex/age structure, both the initial and the follow-up samples were regarded as representative of the total immigrant population from the ex-Soviet Union to Israel between 1989 and 1992 (State Statistics, 1993). The mean length of stay in the country for this subsample was 25.8 ± 8.0 months in the first assessment (range 3-39 months) and 38.9 ± 8.0 months (range 14-52 months) in reassessment. In addition, two comparison groups matched by gender, age and marital status variables to the total immigrant sample were used in this study: a sample of 154 Israeli natives and a =



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Note: T°-o-12 months time at examination

Table 1 characteristics of


prior to planned immigration to Israel; T1-T~ - intervals between time at immigration and

sample of 60 Jewish potential immigrants to Israel. The first control group was formed from subjects seeking help from primary care settings, in which they have turned for various somatic complaints. The group of the so-called potential immigrants was collected at Jewish Agency branch in Dnepropetrovsk (the Ukraine). Subjects were assessed at some point within a 1-year period before their planned emigrating to Israel by mean of our research associates. The assessment has been carried out when the potential immigrants turned for consultation get an immigration visa. Table 1 presents immigrants and potential immigrants. to



characteristics of the

Measures The community survey used two questionnaires which were initially developed and delivered in Russian: the Talbieh Brief Distress Inventory (TBDI) and Demographic Psychosocial

Inventory (DPSI). Psychological distress and symptomatology were assessed using the TBDI. Its properties, internal consistency and validity, as well as a comparison to other distress rating scales in

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outpatient and the general immigrant populations, were reported in detail elsewhere (Ritsner et al. 1995a, 1997; Ritsner & Ponizovsky, 1998). Briefly, it is a self-administered questionnaire of 24 items drawn from two previously developed scales: the PERI - Demoralization Scale (PERI-D) and the Brief Symptom Inventory (BSI), which have been extensively used in socio-psychiatric surveys around the world (Dohrenwend et al. 1986; Derogatis & Spencer, 1982; Derogatis & Coons, 1993). Responses are scored on a 5 point scale (0 - &dquo;a little bit&dquo; to 4 - &dquo;extremely&dquo;), with higher mean scores indicating more intensive psychological distress and symptomatology. A general TBDI index and six symptom subscales - obsessiveness, hostility, sensitivity, depression, anxiety and paranoid ideation are computed. For the present sample, the reliability coefficients of the TBDI dimensions as measured by Cronbach’s alphas ranged from .72 to .91 (except for the paranoid ideation, which had a reliability of .48). Apart from the demonstrable validity and reliability, the TBDI was chosen because it is brief, easily understood and administered. Based on scores of the TBDI general index, two thresholds for aggregate levels of distress were developed: none or low level of distress (scores < or = 1.0) and high level of distress (scores > or = 2.0). The low threshold was empirically developed on a sample of 154 native-born Israelis, aged 18 to 69 (mean = 0.91, SD 0.2), and the high threshold was estimated on a sample of 125 mentally ill immigrants, seeking help in psychiatric outpatient clinics (mean = 1.93, SD 0.9). The quantitative criteria for the presence of psychological distress syndrome (PDS) was estimated as 1.15 for men and 1.39 for women, through comparisons between distributions of cut off points for the BSI and TBDI (Ritsner et al. -



1995a). list of basic demographic variables as well as items about sources which immigrants had encountered since their arrival in Israel (Ritsner et al. 1995b). In the present study, only gender, age at examination, marital status, years of education and duration of stay in Israel variables were used. The DPSI included



adjustment difficulties,

Procedure All subjects were informed of the nature of the study and thus provided informed consent. The TBDI and DPSI took an average of 20-30 minutes to complete. Subjects were instructed to complete the TBDI with regard to the past month. In order to allay respondents’ concern that truthful responses to questions about mental health status might result in negative consequences for them, the questionnaires were administered confidentially. Confidentiality was ensured by a specific procedure employed by the interviewers by which each respondent’s questionnaire identity code number was the only identifying information.

Data analysis Data were analyzed using the NCSS program (Hintze, 1995). The Chi-square test and t-test made two-group comparisons. An analysis of variance (ANOVA) was used for investigating the main effects of sex, age, marital status, and duration of immigration on the variation in the psychological distress scores. Finally, multiple regression analysis was performed for establishing independent contributions of sociodemographics and duration of residence to distress scores. The level of statistical significance was defined as P < 0.05 for all the


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RESULTS Duration of immigration was classified as the time between the date of arrival to Israel and the examination date. All subjects were divided into 20 groups according to the duration of immigration: 3 months or less (T1), 4-6 months ( T2), 7-9 months (T3), and so on - in order to examine any variation in levels of psychological distress and symptoms among subjects with different duration of immigration. In addition, the potential immigrants (T°) were included in the comparative analyses. Initially, comparisons of aggregate levels of distress were made among actual immigrants, potential immigrants, and native-borne controls. These comparisons showed that the TBDI mean scores for the potential immigrants (1.19, SD 0.6) and the actual immigrants (1.29, SD = 0.7) were similar, but both the means were significantly higher than Israeli control mean (0.91, SD = 0.2; p < .01). Figure 1 presents the psychological distress scores of the subjects grouped according to the 3-month intervals since immigration. Overall distress scores differed significantly for these groups (F = 4.43, d.f. = 20/2,378, P < 0.001). The distress scores displayed a step-bystep escalation among those with time since immigration under 27 months (when scores peaked), and scores declined to a normal level among those who spent in Israel over 27 months. The scores tended to elevate somewhat in those residing 54 months and over. Thus, a two-phase temporal pattern of distress was ascertained: an escalation phase and a reduction =

phase. Figure 2 shows the >



five years, the

1-month prevalence rates for highly distressed subjects (the TBDI score

periods. Overall, for immigrants with a length of residence under prevalence rate was 15.6% (370/2,378; 95% CI 14.1-17%). However, at





1. Distress level for 20 time


after resettlement (TBDI

general index)

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Figure 2.



rate of



immigrants by general index > 2.0)

20 time


after resettlement (TI3I)I

the 27th month after arrival, this rate had reached 24% (95% CI 18.3-30.2%), and at the 44th month it had declined to 4% (95% CI 0-9.2%). To verify the two-phase pattern of change in distress scores obtained from examination of cross-sectional data, the longitudinal analysis below was conducted. The sample of 199 subjects who were examined twice (with a 1-year interval between assessments) was divided into three groups according to the time since immigration when the initial and follow-up examinations were carried out. The first (n = 17) consisted of subjects who were assessed twice under 27 months, the second (n 95) included subjects assessed twice after 27 months, and the third (n 86) comprised subjects who were evaluated initially under 27 months and reevaluated after 27 months. No differences were found between the measurements in group 1 and 2, while in group 3 distress scores significantly decreased over the follow-up time (Wilcoxon test for matched pairs, z 2.56, p < 0.01). Thus, the above two-phase pattern of distress obtained according to cross-sectional data was confirmed longitudinally. An ANOVA was also performed for six psychological symptoms (subscales of the TBDI) in relation to one pre-immigration and eight extended post-migration periods (from 6 months to 1 year). All A~1®VAs were highly significant: from F 12.7, d.f. 8, P < 0.0001 for depression to F =3.1, d.f. 8, P < 0.005 for paranoid ideation. Thus, all symptoms replicated the typical two-phase time pattern that was established earlier for the aggregate level of distress. The impact of sociodemographic characteristics on the temporal pattern of distress was examined. The above time pattern was shared by both sexes (Table 2). It was replicated for all age groups, except subjects in their forties (Table 3). Married subjects as well as divorced/widowed subjects (but not singles) have showed the typical time pattern of distress =








(Table 4). To establish the


of the


between time since

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immigration and


Table 2 Distress

Note: TBDI


score ± SD


intensity according to time since immigration


Adjusted difference from


mean -



psychological distress, we performed a two-step multiple regression analysis controlling for three potentially confounding variables - sex, age, and marital status. In the first step, these three control variables were entered and then, in the second step, time since immigration was entered. Because of the effect of time since immigration is not linear, we split this variable, comparing the subjects who had been in Israel for 0-27 months versus those with longer periods of residence. The

Note: TBDI


mean score

Table 3 between psychological distress and

± SD are shown.

length of immigration according to age

Adjusted difference from the mean




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134 Table 4


relationship between psychological distress and length of immigration according to

Note: TBDI

mean score



marital status


In the first of the two-step multiple regression analysis of sex, age, and marital status, the was 0.10 (F = 88.7, d.f. = 2/2,374, p < 0.001). In the second step, analyzing

cumulative r2

the variable of time since immigration, the cumulative r2 was 0.13 (F 83.2, df 2/2,374, p < 0.001). Altogether, the four variables exerted a significant effect on psychological distress, explaining 13% of the variance in distress scores. By themselves, the three control variables accounted for 10% of the total variance in distress scores. Thus, adding the time since immigration variable increased the explanatory power of the prediction by 3%. =



special strengths of this study are a large community sample consisting of voluntary immigrants, partly longitudinal design and the inclusion of comparison groups of potential immigrants and native-born Israelis to ascertain whether a specific phase of psychological distress occurs after resettlement. Of course, we are aware that the chosen design is less rigorous than it would ideally be needed to execute this very complex task. A prospective longitudinal design with repeated measures in the same representative sample before and after immigration would be the preferred design. Such a study, however, is extremely difficult and costly to perform. (To the authors’ knowledge there is the single study in the world literature - Scott & Scott’s (1989) longitudinal study of mixed ethnicity immigrants to Australia). We have undertaken numerous interviews in an attempt to compensate for the obvious limitation in our design. The representativeness of this study sample allowed us to investigate the variation in levels and symptoms of psychological distress among immigrants with


duration of residence in the country under 5 years.

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The findings of the present study can be summarized as follows. Firstly, psychological distress is significantly higher in the immigrants than that in the Israeli natives but not in a sample of potential immigrants. Secondly, the immigrants pass through at least two phases of developing psychological distress: the first phase is characterized by elevated distress scores (the escalation phase), and the second phase by a decline of distress reaching and sustaining a normal level (the reduction phase). Third, the escalation phase occurs during the first 27 months after arrival. The reduction phase continues to the end of the fifth year. Fourth, the temporal pattern was shared with both sexes and all age groups (except for immigrants in their forties), as well as married and divorced/widowed, but not single immigrants. Of course, this is not to say that time is the only factor involved or that the differences in psychological distress of subjects is due to time since immigration alone. Time absorbs into itself numerous events and modulates the activity of a variety of factors, each of which intersects with many others. Which alternatives (apart from the influence of time) could be considered to explain why immigrants arriving 27 months earlier had higher levels of morbidity than those with longer period since immigration? It is possible to suggest that the political and socioeconomic climate of the time was not similar for the former and the latter groups. Alternatively absorption of resources of the receiving society, both material and emotional, may have exhausted over time. Possibly immigrants who arrived earlier were different in other ways. Unfortunately, the design of this study can control for only a limited number of confounding factors, while many others are left out (e.g., unemployment, housing problems). Therefore, this study, like most investigations in the fields, is left with describing different temporal patterns of migrant well-being rather than explaining them. Nevertheless, the patterns we found do not contradict common sense and our experience of dealing with immigrant distress for an extensive period. Consistent with Beiser’s (1988) and Pemice & Brook’s (1996) data, our findings did not support the existence of any distress-free period during the first 2.5 years after immigration. We suggest that the idea that the initial period after resettlement is euphoric, derives from clearly methodologically limited studies (small-size, clinical-based or ethnically heterogeneous samples and mixing refugees together with immigrants). On the other hand, our data do not support Pemice & Brook’s (1996) general conclusion that no definite crisis within six after resettlement exists. period years The question of the existence of certain phases of resettlement characterized by greater emotional distress must be answered affirmatively. When does the distress period begin? and, How long does it continue? Authors have suggested that the distress period can start at a variety of times since migration: within 6 months after arrival (Tyhurst, 1982; Nguyen, 1984); between 10-30 months (Beiser, 1988; Rumbaut, 1985); or even within 6 years (Sluzki, 1986). The findings of this study, which identify the distress period during the 27 months after arrival, is consistent with Beiser’s and Rumbaut’s results. The discrepancies among the cited studies regarding the precise timing of distress phases may be attributed to differences in the following sets of dynamic factors: sociodemographic variables and preimmigration factors (cultural background and the position which the immigrant occupied as an individual and as member of a group in the country of origin), factors specific to the migration process (voluntary or involuntary migration), and post-migration factors (a host of factors which are associated with the interaction with and the attitude of the receiving society). The relatively later peak period in our sample may be related to the voluntary

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character of resettlement and the greater social support of the host society. Because Israel is a country in which the constant flow of immigrants is a well-established norm (Shuval, 1993), many Israelis identify with the newcomers as a result of their own past experience as immigrants. Longitudinal studies have shown that the level of psychological distress in an individual fluctuates over time, and at the same time period (phase), different immigrants may show diverse trends of distress (Ritsner et al. 1997). Therefore, we tried to verify our crosssectional approach with longitudinal data. The longitudinal part of the study was carried out on only 199 subjects with greatly varying time-intervals that had elapsed since immigration. However this analysis indirectly confirms that the two-phase temporal pattern of psychological distress is not artifact. This conclusion becomes more convincing in the light of data of multiple regression analysis controlling for potentially confounding variables - sex, age, and marital status. The most surprising finding of this study is the relatively elevated level of psychological distress among potential immigrants in the former USSR (specifically, in Ukraine). Their mean distress score (1.2) did not differ significantly from that reported by the immigrants passing across the first phase of adaptation in Israel (1.3). Of course, it may be artifact associated with a small number of the controls, but it is possible also that the elevated distress in potential immigrants is related to their decision to immigrate. One cannot exclude that preparing for immigration as well as anticipating the possibility of many losses and adjustment difficulties may result in increased distress prior to immigration. Alternatively immigration-unrelated factors, such as socioeconomic and political instability occurring in the former Soviet republics, could be an explanation. Among factors affecting the level of post-immigration adaptation, demographics, such as sex, age, and marital status have been reported to modulate immigrants’ distress. Our findings showed that the latter two had an effect on the time pattern of psychological distress, while the sex variable had no significant effect. Unlike the immigrants of other age groups, the subjects in their forties reported elevated distress across all the study period. We would suggest that these immigrants encountering typical adjustment difficulties are incapable of coping with them in an effective way. Specifically, they experience particular hardships finding paid work (as it has been shown, for instance, for immigrant-physicians in Israel (Ponizovsky et al. 1996)). It is possible that, unlike their younger or older counterparts, the subjects in their forties had higher societal expectations prior to immigration and, therefore, their disappointments had a considerable long-term negative effect on their post-immigration mental health. Regarding marital status, we found that single immigrants were the only category deviating from the common time pattern of post-immigration distress - they showed insignificant fluctuations of distress at a relatively low level for the study span. This result is inconsistent with Beiser’s finding (1988) that unmarried or otherwise unattached refugees experienced the highest levels and longest duration of depression. The disagreement between the two studies could be explained by less social support being received by refugees in Canada than immigrants in Israel. Although we do not have data regarding the level of social support in our study population, this explanation seems fairly reasonable in the light of Flaherty et al.’s study (1988) which found that a difference in levels of demoralization between Jewish immigrants in Israel (lower) and the United States (higher) was related to greater social support received by the former, as compared with the latter.

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Limitations of the present study deserve mention. Because mass immigration to Israel started relatively recently, our data cover only the first 5 years of resettlement. It is possible that a longer span of observation could find a different time pattern of psychological distress, e.g., a recurrent course. The modest elevation of distress ratings among those who had spent four years in the country indicates that such possibility cannot be excluded. Another shortcoming is related to the statistically small number of potential immigrant controls. Again, a thoroughly prospective investigation would be required to confirm or reject the twophase pattern of distress. A more extended control sample might find that psychological distress does not appear in potential immigrants prior to their resettlement. The strongest implication of this study is that practical aid and support focusing on the strengthening of individual coping strategies should be offered to immigrants immediately after arrival and be available at least during the escalation phase of distress. The results of this study suggest that the conditions existing in Israel enable a great majority of new immigrants to cope with migration distress and adapt to the host culture within the first 2-2.5 years of resettlement.

ACKNOWLEDGEMENTS in part by the Ministry of Absorption, the Ministry of Health and the Ministry of Science (Israel). We would like to thank our research assistants I. Finkelstein and V. Shinkarenko for participating in the collection of control data and D. Pollock for improving the early version of the manuscript.



BARWICK, C.S.L. (1986) Services

to immigrants: The new specificity of transcultural psychiatry. Paper presented of the Canadian Psychiatric Association. BEISER, M. (1988) Influences of time, ethnicity and attachment on depression in Southeast Asian refugees. American Journal of Psychiatry, 145, 46-51. BERRY, J.W. (1990) Acculturation and adaptation: health consequences of culture contact among circumpolar peoples. Arctic Medicine Research, 49, 142-150. BERRY, J.W. & KIM, U. (1988) Acculturation and mental health. In Cross-cultural psychology and health. Towards applications (eds. P. Dasen, J.W. Berry & N. Sartorius), London: Sage. BRINK, P.J. & SAUNDERS, J.M. (1976) Transcultural Nursing: A Book of Reading. Englewood Cliffs, NJ: Prentice-Hall. BOMAN, B. & EDWARDS, M. (1984) The Indochinese refugee: An overview. Australian & New Zealand Journal of Psychiatry, 18, 40-52. DEROGATIS, L.R. & SPENCER, R.M. (1982) The Brief Symptom Inventory (BSI): Administration, Scoring and Procedures Manual. Baltimore: Clinic Psychometric Research. DEROGATIS, L.R. & COONS, H.L. (1993) Self-report measures of stress. In Handbook of Stress: Theoretical and Clinical Aspects. Second Edition (eds. L. Goldberger & S. Breznittz). New York: The Free Press. DOHRENWEND, B.P., LEVAV, I. & SHROUT, P.E. (1986) Screening scales from the Psychiatric Epidemiology ReInterview (PERI). In Community Surveys of Psychiatric Disorders (eds. M.M. Weissman, J.K. Myers & C. Ross). Brunswick, New Jersey: Rutgers University Press. FACTOUROVICH, A., RITSNER, M., MAOZ, B., LEVIN, K., MIRSKY, J., GINATH, Y., SEGAL, A. & BAR NATAN, E. (1996) Psychological Adjustment and Distress Among Soviet Immigrant Physicians: Distress and Self-Assessments of its Sources. Israel Journal of Psychiatry & Related Sciences, 33, 32-39. to the 36th Annual


Downloaded from by Alexander Ponizovsky on November 24, 2007 © 1999 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.


FLAHERTY, J.A., KOHN, R. & GOLBIN, A. (1986) Demoralization and social support in Soviet-Jewish immigrants to US. Comprehensive Psychiatry, 27, 149-158. FLAHERTY, J.A., KOHN, R., LEVAV, I. & BIRZ, B. (1988) Demoralization in Soviet-Jewish Immigrants to the United States and Israel. Comprehensive Psychiatry, 29, 558-597. GRINBERG, L. & GRINBERG, R. (1984) A Psychoanalytic Study of Migration: Its Normal and Pathological Aspects. Journal of the American Psychoanalytic Association, 32, 13-38. HERTZ, D.G. (1988) Identity-Lost and found: patterns of immigration and psychological and psychosocial adjustment. Acta Psychiatrica Scandinavica, Supplement 334, 159-165. HERTZ, D.G. (1993) Bio-Psycho-Social Consequences of Migration Stress: A Multidimensional Approach. Israel Journal of Psychiatry & Related Sciences, 30, 204-212. HINTZE, J.L. (1995) User’s Guide. NCSS 6.0. Statistical System for Windows. Kaysville, Utah: Number Crunchier Statistical


LEVAV, I. (1989) Somatic symptoms among older Soviet Immigrants: an exploratory study. International Journal of Social Psychiatry, 35, 350-360. KUO, W. (1976) Theories of migration and mental health: An empirical testing on Chinese-Americans. Social


Sciences & Medicine, 10, 297-306. LEHERER, Z. (1993) The Psychology of Immigration. A Literature Review. Israeli Defence Forces & JDC-Brookdale Institute of


and Human

Development, Jerusalem.

NGUYEN, S.D. (1982) The psycho-social adjustment and mental health needs of Southeast Asian refugees. Psychiatry Journal of University Ottawa, 7, 26-35. PERNICE, R. & BROOK, J. (1996) The mental health pattern of migrants: is there a euphoric period followed by a mental health crisis? International Journal of Social Psychiatry, 42, 18-27. PONIZOVSKY, A., GINATH, Y., FACTOUROVICH, A., LEVIN, K., MAOZ, B. & RITSNER, M. (1996) The impact of professional adjustment on the psychological distress of immigrant physicians. Stress Medicine, 12, 247-251.

PONIZOVSKY, A., SAFRO, S., GINATH, Y. & RITSNER, M. (1997) Suicide ideation among recent immigrants: An epidemiological study. Israel Journal of Psychiatry & Related Sciences, 34, 139-148. PONIZOVSKY, A. & PERL, E. (1997) Does supported housing protect recent immigrants from psychological distress? International Journal of Social Psychiatry, 43, 79-86. RITSNER, M., MIRSKY, J., FACTOUROVICH, A., SEGAL, A., SHLAFMAN, P., LEVIN, K., BAR NATAN, E., MAOZ, B. & GINATH, Y. (1993) Psychological adjustment and distress among Soviet immigrant physicians. Israel Journal of Psychiatry & Related Sciences, 30, 244-254. RITSNER, M., RABINOWITZ, J. & SLYUZBERG, M. (1995a) The Talbieh Brief Distress Inventory: A brief instrument to measure psychological distress among immigrants. Comprehensive Psychiatry, 36, 448-453.

RITSNER, M., RABINOWITZ, J. & SLYUZBERG, M. (1995b) The Demographic Psychosocial Inventory (DPSI): A new instrument to measure risk factors for adjustment problems among immigrants. Refuge, 14, 8-15. RITSNER, M., PONIZOVSKY, A., CHEMELEVSKY, M., ZETSER, F., DURST, R & GINATH, Y. (1996) Effects of immigration upon the mentally ill does it produce psychological distress? Comprehensive Psychiatry, 37, -


RITSNER, M., PONIZOVSKY, A. & GINATH, Y. (1997) Changing patterns of distress during the adjustment of recent immigrants: a one-year follow-up study. Acta Psychiatrica Scandinavica, 95, 494-499. RITSNER, M. & PONIZOVSKY, A. (1998) Psychological symptoms among immigrant population: A prevalence study. Comprehensive Psychiatry, 39 (1): 21-27. RUMBAUT, R.G. (1985) Mental Health and the Refugee Experience: A Comparative Study of Southeast Asian Mental Health: Treatment, Prevention, Services, Training and Research. Rockville, Maryland, National Institute of Mental Health.

SCOTT, W.A. & SCOTT, R. (1989) Adaptation of Immigrants: Individual Differences and Determinants. Oxford:

Pergamon Press. SHUVAL, J. (1993) Migration and

stress. In


of Stress (eds. L. Coldberg &

Press. SLUZKI, C.E.


Breznitz). New York:


(1986) Migration and family conflict. In Coping with Life Crises (ed. R.H. Mooz). New York: Plenum. SOKOLOFF, B., CARLIN, J. & PHAM, H. (1984) Five-year follow-up of Vietnamese refugee children in the United States. Clinical Pediatry of Philadelphia, 23, 565-570. TYHURST, L. (1982) Coping with refugees. A Canadian experience: 1948-1981. International Journal of Social Psychiatry, 28, 105-109.

Downloaded from by Alexander Ponizovsky on November 24, 2007 © 1999 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.


VANG, T.F. (1984) Acculturation and mental health: A study of Hmong Social Science & Medicine, 18, 87-93. WESTERMEYER, J., NEIDER, J. & CALLIES, A. (1989) Psychosocial adjustment of Hmong refugees during their first decade in the United States. A longitudinal study. Journal & of Nervous Mental Disease, 177, 3132-3139. WESTERMEYER, J., NEIDER, J. &



1.5 and 3.5 years

Michael Ritsner, MD, PhD, Israel





Alexander Ponizovsky, MD, PhD, Institute for Post Hefer 38814, Israel



Psychiatric Research,

Hadassah Medical

School, Jerusalem,

Sh’ar Menashe Mental Health Center, Mobile

Correspondence to Dr. Ponizovsky

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